Women wait in MSF's mobile clinic to register their names to see a doctor in Northern Syria.

After two years of an extremely violent conflict that the UN estimates has killed more than 70,000, the people of Syria are mired in a humanitarian catastrophe.

Despite repeated requests, Doctors Without Borders/Médecins Sans Frontières (MSF) has not received permission from the Syrian government in Damascus to work in the country. But the organization has been able to open three hospitals in opposition-held areas in the north, where assistance remains well below the level of the needs.

1. Health Care in Danger

From Repression to All-Out Destruction

Since the first anti-government protests broke out in Syria in March 2011, the country has spiraled into all-out war between the national army and an array of opposition groups. As often happens, however, civilians have paid the highest price.

Now, the conflict continues to intensify, showing no signs of abating, and taking a particular toll on the country's health sector. Health workers and medical facilities are still receiving threats and medical structures are targeted and destroyed. This report is designed to reflect on the devastation two years of war has wrought on the provision of medical care in Syria.

Injured People Arrested, Doctors Hunted Down

As the Arab Spring came to full flower in the Middle East, Syria experienced its first major protests on March 15, 2011, in the town of Damas. As the weeks wore on, the number of protesters multiplied, but they soon found themselves under fire as security forces attempted to quell the then-peaceful uprising. Injured activists assumed that they could seek care at public or private hospitals should they need it, as health structures had the technical means, expertise and resources necessary to treat trauma. Syria’s health care system had once functioned to a high standard, after all. But very quickly the health structures themselves were targeted as part of the campaign of repression.

Accounts from doctors and patients revealed that hospitals were being scrutinized by the security forces, and that people were being arrested and tortured inside them. Doctors risked being labeled “enemies of the regime” for treating the injured, which could lead to their arrest, imprisonment, torture or even death. People hurt at protests therefore stopped going to public hospitals with similar fears of being tortured, arrested, or refused care, and were essentially forced to entrust their health to clandestine networks of medical workers.

In Deraa, Homs, Hama, and Damascus, medical care was still provided out of public view. Makeshift hospitals were set up inside homes near protest sites. Health centers treating the injured would provide false official diagnoses in order hide the fact that they were treating people wounded at demonstrations. The major concern for doctors working in these underground networks was their safety.

Health Care Goes Underground

As fighting began and later intensified, a rising number of medical facilities were affected. In July 2011, the Syrian army deployed tanks in the city of Homs; in February 2012, the city was under constant attack by snipers, shelling and aerial bombing by the government's Air Force. Aid efforts continued clandestinely, however, with medics working to treat the injured even as bombs rained down around them. The authorities refused to allow international humanitarian aid into the country. A ceasefire to evacuate the wounded was also rejected.

A handful of makeshift hospitals were providing health care close to the conflict zones. They had been set up in caves, individual homes, farms and even in underground bunkers. Following initial treatment and stabilization, patients were transferred to hospitals in safer locations.

MSF began responding to the conflict in Syria by donating drugs and medical supplies to doctors secretly treating the wounded in these clandestine facilities. In June 2012, MSF set up its first hospital in northern Syria, along an evacuation route being used to transport the wounded to safe havens. In the space of six days, MSF set up a secret surgical hospital inside an empty family home. A few months later, in September 2012, MSF opened two more hospitals—in Aleppo and Idlib provinces—both in northern Syria and both in areas controlled by opposition groups.

Despite repeated requests for access to work in government-held areas, MSF has not been able to secure authorization to do so. MSF can therefore only provide direct assistance and deploy teams in opposition-held territories and can mainly speak of what its teams see in those locations. The Syrian government, and more particularly its Air Froce, has been targeting health centers in air raids. MSF assesses the security situation of its teams on a daily basis, and ensures that the hospitals remain demilitarized, neutral spaces.

Health Structures Targeted and Destroyed

As the repression of peaceful protests became a clear government policy, the opposition took up arms, eventually beginning to take control of certain areas, which spurred the conflict into even more brutal territory. Again, the health sector was gravely affected. Medical structures were targeted and destroyed while health care workers were threatened or killed. Providing medical care was transformed into an act of resistance, a crime, and medical structures became military targets.

In July 2012, a new front opened in Aleppo. The economic capital of the country was ravaged by aerial bombardments and ground fighting. Buildings, including medical facilities, were decimated; the blood bank supplying the region’s hospitals was among the first to go up in smoke.

Dar El Shifa, the largest private hospital in Aleppo, was situated in an opposition-controlled area in the east of the city. It provided care for victims of violence until it was bombed during an air raid that August. Although the operating theater was destroyed, the emergency ward continued to operate and saw about 200 people per day. But in late November, it, too, was demolished by bombing and rendered inoperable.

An emergency ward was discreetly set up in the neighborhood to care for the steady flow of wounded who needed treatment. To minimize risk, medical activities were decentralized into different locations. Two private clinics took on Dar El Shifa’s caseload; the wounded were brought in on stretchers by people on foot—until one of the two clinics was also bombed.

Hospitals in Syria are now being used as a tool in the military strategies of the parties to the conflict. In “liberated” areas, some hospitals are being set up or transformed into “Free Syrian Army (FSA) hospitals” or hospitals established with the goal of “supporting the Revolution.” As a result, these hospitals are at risk of becoming targets and civilians are rarely accepted.

Opposition military bases have been established close to some makeshift hospitals—even, in some cases, in the same building. These hospitals are at serious risk of being caught in the middle of fighting, or even directly hit in an attack.

According to the Syrian authorities, 57 percent of public hospitals in the country have been damaged and 36 percent are no longer functional. For a complete picture of the devastation, though, makeshift hospitals set up by the opposition and subsequently destroyed by the army should also be added to the tally.

Hospitals in Danger

Dr K. is a surgeon (his full name is being withheld) who provides surgical care for the wounded in a 30-bed private hospital in northwestern Syria:

“A missile landed about 50 meters from the hospital. The windows were blown out. The army had been targeting the hospital. This is the only functioning hospital in this city, and it also serves 15 other towns and villages. A population of 200,000 rely on this facility. We’re able to work and there are enough doctors, but there’s a lack of drugs and medical supplies. Our stocks have run out. Right now we need X-ray films, external fixators. . . . We can’t do lab analysis here anymore so people have to go elsewhere.

The army’s positioned about 20 km [12 miles] away from here. They took over the city twice last year. When they came, I had to leave because they arrest doctors who treat the wounded. For them, doctors are as good as terrorists. They came into the hospital and took a patient right from the ward.

Why do I keep on with this [work]? Because if I leave, nobody else will care for the sick. I’ve had multiple threats but I’ve managed to escape so far because I’ve had friends who warned me.”

Difficulty in Caring for the Wounded

Given the constant bombing attacks, there is a clear need for trauma surgery, and treating the war-wounded has become a priority. Providing this kind of care, however, is a very difficult undertaking.

Drug production and distribution hubs in Aleppo have shut down; stocks are virtually exhausted. Supply from Damascus is no longer possible; by and large, the only way to bring supplies into Syria is through unofficial supply routes from neighboring countries.

Moreover, the power plants serving the Aleppo region have been destroyed. Hospitals are running on generator power, but obtaining fuel for them is very difficult. These facilities function as well as they can, given the shortage of medical supplies. “I saw one emergency ward where they had no sterilization tools," says MSF doctor Natalie Roberts, who recently returned from Aleppo. "They had to do sutures with materials that had already been used."

There is also a lack of ambulances to transport the injured to hospital. Patients are transported on motorbikes and in personal vehicles—both of which are generally not equipped to stabilize wounded patients. There are only about a dozen ambulances in working condition in all of Aleppo province. What’s more, vehicles such as ambulances are very visible and thus, of course, vulnerable to gunfire.

The humanitarian emergency in Syria has made it necessary for people to take on jobs for which they are not trained. Many Syrian health care workers have fled the country, and those who remain do the best that they can. Among those who remain are specialists, doctors-in-training and surgeons with no experience operating on war-related injuries. Dentists are performing minor surgeries, pharmacists are treating patients and young people are volunteering to work as nurses.

“This is a war, and everyone’s got to do it all,” says one of them.

No Blood Bank

Large quantities of blood are needed in order to treat patients with conflict-related injuries. The only blood bank in the Aleppo area was demolished in an air raid when the fighting began, so hospitals in the area have been struggling to deal with this difficult situation for months.

Finding donors is not the problem; many people are happy to give blood. The issue is keeping the bags of blood cool. Most hospitals are not equipped with refrigerators. If a facility is fortunate enough to have one, a generator is required to keep it running due to the lack of power in the region.

In addition, hospitals in the area do not have the testing materials required to analyze and determine blood type. As a result, people who need urgent blood transfusions are given blood without the necessary tests having been carried out. The consequences can be fatal. “I heard about a pregnant woman who had gone to hospital to give birth,” says Dr. Natalie Roberts. “She needed a blood transfusion which was given but the blood used was not the right type. She died, and it is not clear whether it was the hemorrhage or the transfusion itself that killed her.”

MSF has provided a fridge, money for fuel, testing supplies and training to set up a new blood bank. This new facility now supplies hospitals in the Aleppo region. It is still at risk of becoming a military target.

2. Civilians Caught Up in the Cycle of Violence

In the regions in northern Syria where MSF is working, people have suffered great loss and devastation. This is especially true in the urban and semi-urban areas that are bombed indiscriminately and where people gather in large numbers at places such as markets and bread queues that have been specifically targeted by the Air Force.

In addition to the physical devastation, the country’s social and economic systems have broken down, and civilians are the first to suffer. Despite a massive outpouring of local solidarity, the ongoing conflict has brought the health care system to its knees, while living conditions have severely deteriorated. Meanwhile, resources are running out and peoples’ capacity to help each other is being strained.

Civilians Terrorized

Since starting work in northern Syria, MSF has witnessed how the violence directly affects civilians. Patients injured by shrapnel or bombs at markets, breadlines or elsewhere often get care only thanks to the efforts of fellow citizens who are willing to help each other despite the dangers that accompany efforts to transport the wounded to health centers.

“Some villages are hit by rocket fire or have explosives dropped on them by helicopters on a daily basis,” says Katrin Kisswani, an MSF coordinator in Syria. “This has had a devastating effect on people. A few days ago, a helicopter dropped a couple of barrels with TNT and bits of metal inside right in the middle of a village. We treated the victims in our field hospital—some of them were women and children.” During exploratory missions, MSF teams have also come into contact with people who had been living without any outside assistance at all.

Civilians have been profoundly traumatized by the conflict and live in constant fear of gunfire, rockets and missiles. They are even suspicious of one another: some will not give their real names out of fear that their stories would become public and their families would be threatened.

On January 13, 2013, 20 people were killed and 99 injured after a marketplace was bombed in Azaz. MSF treated 20 of the wounded, all of them civilians, including five children. Only two days later, MSF provided emergency treatment to another 44 patients after several barrels of explosives were dropped on a village and a rocket landed in Idlib province.

Fear of Planes

Faotum H. sits outside an MSF hospital after visiting her grandson. The 55 year-old recalls the buzzing of Syrian warplanes over Azaz, a town in northern Syria close to the Turkish border, in the summer of 2012. An airstrike hit her home, though no one in her family was injured as they were not home, but the second floor was completely destroyed. The large hole and debris from the impact remained as physical reminders of the attack.

A few months later Faotum’s grandson, six year-old Mohammed, was playing at home with his brothers when warplanes flew over Azaz again. “The kids panicked and started to run downstairs," she says. "Mohammed did not see the hole and fell down it, broke his leg and injured his head." It wasn’t an airstrike, but the sound of the planes was enough to frighten the children and send them running. The boy was treated at an MSF field hospital in the region. His grandmother was relieved by the care he got, but she also remembers how hard it was to find the additional medical assistance he needed. “We were told in Azaz that we had to go to Turkey," she says. "In the end we came here, and he was admitted.”

Man Wounded Waiting in a Bread Queue in Halfaya (Hama Province)

“One afternoon at the end of December, I was waiting at the bakery to buy bread. There were about 300 people in the queue [because] it's the only bakery in town that’s still open. I’d been waiting for three hours when suddenly a plane flew overhead and two missiles hit us.

There was screaming all around me; many people had been wounded. I felt disoriented. I felt as though my lips and tongue were burning. Injured people were loaded into vehicles. I was taken to a health center, first in a wheelbarrow, then by motorcycle taxi. I was unconscious for three days. The second day, my brother brought me to another medical center before finally bringing me here to the MSF hospital in a van. That’s when they operated on me.

I’m still having problems with my ears—there’s a constant ringing in them and I can’t really hear.

The incredible thing is that my two daughters came away from it okay. A semi-collapsed wall protected them from the explosion, so they only had a few cuts and scrapes.”

At the MSF hospital, a surgeon cleaned this man’s wounds and the parts of it that had become necrotic, and sutured the small cuts on his face. The size of the wound on his left shoulder and the severity of the injury to his right hand meant that he had to be transferred to a hospital in Turkey for reconstructive surgery, as the MSF facility isn’t equipped to carry out such complex procedures.

A Health System in Collapse

Before this conflict, Syria had a well-functioning health system. The country has trained health workers, medical expertise and its own pharmaceutical industry. But today, those resources are almost completely depleted, on all sides of the frontlines. Health networks have broken down because of supply problems and drug shortages resulting from the collapse of the pharmaceutical industry or indirectly from international sanctions imposed on Syria.

The intense violence makes it very difficult to access the health care that is still available. In Homs, Aleppo and in the area around Damascus, snipers present a constant danger. Moving from one area to the other is often impossible, and entire communities are consequently deprived of medical care. In a medical emergency, patients face a grim dilemma: forgo medical attention or risk their lives to get it.

Patients are often sent to under-resourced health facilities, if they’re lucky enough to receive any care at all. In many hospitals care is first given to combatants, but large numbers of patients also need medical attention—be it for chronic illnesses (e.g. diabetes, cardio-vascular diseases, and kidney failure), obstetric care and post-operative care—and have difficulty accessing care.

“Many health facilities have closed because they lack essential equipment, and others are concentrating only on trauma. This makes it that much more difficult for people to access health care,” says Miriam Alia, an MSF medical coordinator in Syria. “In the regions where we’ve been working, the children haven’t received vaccinations in the last 18 months. They’re not protected against contagious diseases like measles and tuberculosis. Sanitary conditions are worsening as water is so scarce, which also increases the risk of disease.”

Recently there have been reported outbreaks of thousands of cases of cutaneous leishmaniasis in northern Aleppo province. Local doctors in Deir ez-Zor reported to MSF that 1,200 cases of typhoid fever, which can be fatal, and 450 cases of cutaneous leishmaniasis had been registered by the end of February. Drugs for tuberculosis have been unavailable in the region for months.

Diabetic patients require regular treatment and follow-up but at present they have been left to their own devices. “Without insulin, patients are coming in with blood sugar levels of up to 5 grams/liter, and we have had some with a gangrenous foot that requires amputation,” says Anne-Marie Pegg, an MSF emergency doctor.

Giving Birth in a War-Torn Country

Prior to the conflict, 95 percent of Syrian women gave birth with a skilled birth attendant. With the collapse of the health system, this is no longer an option for most. If a pregnant woman is lucky, she might give birth with the help of a midwife or a traditional birth attendant. However, women with complicated deliveries requiring surgical care have great difficulty in finding an appropriate facility.

This past February 1, a woman gave birth to twins by Caesarean section at an MSF clinic in northern Syria. The father of the twins said they searched for two weeks to find a hospital capable of performing the surgery.

In the MSF hospital in Aleppo province, deliveries climbed from 56 in November 2012 to 183 in January 2013. MSF’s medical teams have seen an abnormally high number of miscarriages and premature births among their patients, more than 30 in December and January alone. This is due to the stress generated by the conflict.

Deteriorating Living Conditions

“Most of the families have fled the village," says a housewife from Idlib province. "There’s no gas, electricity, or bread, and the phone lines are dead. There is nothing to live off."

The cost of living has increased considerably, and bombing has cut off the water and electricity supply in the north of the country. Since the beginning of December 2012, there has been no electricity in the eastern part of Aleppo, in Al Bab, or in the entire region up to Kilis. The price of fuel has risen significantly and now that it is winter, people keep warm with wood or fuel stoves, which are often the cause of serious accidents.

“In Aleppo, everything that even resembles an administrative building has been bombed," says MSF’s Elisabeth Jaussaud, who recently returned from the area. "There’s no power in Aleppo save for the generators. The city is littered with piles of rubble that block the streets so that cars or armored vehicles can’t pass. Rubbish too is piling up all over the city.”

Another issue is the supply of food. Food prices have increased sharply in the northern provinces of Syria where MSF is present (Latakia, Idlib and Aleppo), so there have been major shortages of flour and baby formula. In response, MSF has donated baby formula and several tons of flour in Idlib and Deir ez-Zor provinces.

“Only a few markets are open," said one village leader who asked that his name not be used. "Factories are closed. When food and vegetables are available, they are too expensive."

Displaced and Isolated People

According to the Office of the UN High Commissioner for Refugees (UNHCR), two and a half million Syrians have been displaced inside the country since the first protests broke out two years ago. Most of the displaced people are not living in camps. Many instead have settled in buildings and public places, or are constantly on the move. Living conditions are very poor for the internally displaced, while host communities are also under strain.

Access to large parts of the country is still very difficult, which hinders the delivery of assistance, especially the further south one travels from the Turkish border. It is also difficult for assistance to reach densely populated areas and the desert regions in the east. The food shortages are so acute that current supply and solidarity networks cannot cope.

In areas under government control, such as the western parts of Aleppo city, people are living in enclaves surrounded by the armed opposition. It is impossible to supply humanitarian assistance from Damascus into these areas.

Faced with a situation that is relentlessly worsening, an increasing number of Syrians are fleeing the country. According to the UNHCR, one million Syrians have been either registered or are waiting to be registered as refugees, mainly in the neighboring countries of Iraq, Jordan, Lebanon and Turkey. More than 150,000 arrived in February alone.

So far, aid for Syrian refugees has not been sufficient to effectively respond to their basic needs. Meanwhile, their living conditions have continued to worsen through the harsh winter conditions and sub-zero temperatures.

3. Obstacles to Increasing Aid for Syria

There are major obstacles preventing the increase of aid to both government and rebel-held areas. The government is limiting humanitarian aid, keeping tight control on any aid that flows through Damascus and refusing to allow aid organizations to cross the frontlines from the capital. Meanwhile, in the north of the country, insecurity caused by fighting and bombing is being compounded by political and diplomatic constraints that seriously impact the amount of aid that can be delivered.

Control of Assistance in Government Areas

Since 2012, international aid for Syrians inside the country has been mainly deployed from Damascus by the International Committee of the Red Cross (ICRC), UN agencies (including WFP, UNHCR, UNRWA, and others) and about a dozen international NGOs. This assistance is channeled through the Syrian Arab Red Crescent and local organizations, which are authorized by the Syrian government to distribute aid on the ground. Operations are also carried out under the auspices of the Syrian Vice Minister of International Affairs and Expatriates.

Though there is currently insufficient humanitarian aid to meet the massive needs, it will be difficult to get more—and more effective—aid into the country. For one thing, the government is not permitting any more international NGOs to work in government-held territory—indeed, MSF has been refused access to these areas, despite repeated requests. Also, humanitarian aid organizations are required to distribute aid through local organizations that are already operating at full capacity and whose scope of operations is limited geographically.

These constraints also significantly limit the capacity of aid agencies tolerated by Damascus to reach people in the opposition-held north of Syria. According to Valerie Amos, UN under-secretary-general for humanitarian affairs, other options for aid distribution, such as humanitarian operations led from neighboring countries, are not currently feasible without government authorization or a separate UN Security Council resolution.

Aid to Rebel-Held Areas: Limited and Piecemeal

About a dozen international NGOs are present at the Syrian borders attempting to get aid into the country’s interior. This aid was first limited to sending medical supplies for groups of Syrian doctors working clandestinely to treat injured people in makeshift hospitals (MSF first started supporting these doctors this way). Some aid has been provided in the displaced peoples’ camps along the Turkish border. With the consolidation of territory controlled by the opposition, MSF was able to enter and open three hospitals in the northern Syria. This was done unofficially, given the government's ongoing refusal to allow MSF to work in Syrian territory.

Beyond that, most aid for civilians comes from three sources: the Syrian diaspora, countries “sympathizing” with the opposition (Saudi Arabia, France, Turkey, Qatar, and others), and political and religious solidarity networks. The aid delivered is not surprisingly filtered through the political agendas of these actors.

Meanwhile, as indiscriminate or targeted bombing considerably limits the amount of assistance that can be provided in northern Syria, aid is being distributed through local organizations (such as associations of doctors or businessmen), armed groups, and civil authorities trying to establish themselves (local revolutionary coordination councils, for instance).

In the north, international aid providers struggle to find ways to collaborate efficiently with local authorities and Syrian aid networks. One issue is that there are many representatives and leaders. Humanitarian actors struggle to gauge the importance, the effectiveness, or the reliability of the different representatives they come across, particularly because some of them are affiliated with different and competing political, military, or religious networks.

The final obstacle is administrative. Though neighboring countries tolerate NGOs engaged in cross-border humanitarian operations into Syria, they are not willing to grant them the logistical and administrative support that comes with official permission. Aside from slowing down the delivery of aid, this semi-underground status also conflicts with the financing rules for some donors who are reluctant to fund NGOs carrying out cross-border operations.

What makes this even more of a paradox is that the European Union, Turkey and almost 130 other countries recognize the Syrian national coalition as the sole representative of the Syrian people and provide them with direct financial and (officially non-lethal) military aid. This being the case, it’s hard to see what is stopping Syria’s neighboring countries and these financial donors from officially recognizing and providing financial support to humanitarian cross-border operations.

Danger of Humanitarian Operations Across Front Lines

Although the current set-up is intended to cover all the existing needs in Syria, the national and international aid provided beyond areas controlled by Damascus is limited. This is due to the huge difficulty involved in imposing a temporary ceasefire, which would be necessary to get material and teams collaborating with the Syrian Red Crescent safely across the front lines. A spokesperson for the ICRC who was recently in the country summed it up in a recent public statement: “Mounting cross-line operations is challenging, not least because, as in every conflict, neither side is keen to see us crossing into the area held by their enemy.” Armed rebel groups, meanwhile, show great mistrust towards the Syrian Red Crescent, which is perceived as pro-governmental, despite the dedication its members have shown to their medical mission (since the beginning of the conflict, seven Red Crescent volunteers and eight UN employees have been killed on-mission).

To cover the needs of civilians, the capacity of humanitarian actors to provide impartial aid throughout Syria must be increased and cross-border operations must be facilitated.

Insufficient Aid

At the end of January 2013, more than 60 countries committed to providing more than $1.5 billion in humanitarian aid for the Syrian population. This amount, meant to cover urgent humanitarian needs for the first half of this year, stands in contrast with the small sum that the UN Office for the Coordination of Humanitarian Affairs (UNOCHA) was actually able to obtain to cover its action plan in 2012.

The plan for 2013 includes a regional response for refugees, estimated at $1 billion for 1.1 million people, and another estimated at $520 million for 4 million people “directly or indirectly affected by the current events” inside Syria. Yet, as of February 19, the UN action plan had only received 20% of the necessary financing.

4. Assistance Failing Syrian Refugees

According to official estimates, 1 million Syrian refugees are registered or awaiting registration in Syria’s neighbouring countries—Lebanon, Jordan, Turkey and Iraq. But their actual number could be much higher, as many people are not part of the process to get officially registered. In recent months, as many as 7,000 people have been fleeing Syria each day. Most of them are reported to be women and children.

The situation of the refugees fleeing Syria emphasizes the failure of the international aid system to respond to the Syrian crisis. Although access and security in the neighboring countries are not a major problem, the international aid system has failed to anticipate and respond to the growing needs of the refugees. The massive influx of refugees pouring into Syria’s neighboring countries is further weakening already fragile refugee reception systems and worsening the already dire situation of scattered refugees in Lebanon.

In Jordan and in Iraq the living conditions in the refugee camps are grim. The camps are saturated and hygiene is poor, due to shortages of latrines and showers. People are living in crowded and unheated tents that offer little protection against the bitter winter. Earlier this year rainstorms and snow battered some camps.

In Lebanon, where there are no official camps for Syrian refugees, an increasing number of people live in inadequate collective shelters, farms, garages, unfinished buildings and old schools. According to a survey conducted by MSF in December, 50% of the Syrian refugees in Lebanon were not receiving necessary medical treatment because they could not afford it. Food also is a growing issue. MSF teams have seen cases of women having to feed their babies with tea because they could not afford to buy milk.

Psychological distress is widespread among the refugees, whether they are men, women or children. Most of the refugees interviewed by MSF in Lebanon and Iraq said that they fled Syria because of the insecurity, but also because of the deterioration of living conditions in Syria (shortages of food, water and fuel and lack of access to medical care).

Thousands of Syrian refugees face an unacceptable situation. After fleeing a war zone and leaving everything behind them, people still have to wait weeks or even months before they are officially registered as refugees and receive a much needed assistance. Many families are living in dire conditions with very little assistance, while others are simply not getting any aid at all: roughly one in four of the registered refugees interviewed in Lebanon said they had not received any assistance, while 65% said they had received only partial assistance that did not cover the families’ needs.

For Iraq, Jordan, Lebanon and Turkey, which host nearly all the Syrian refugees, the cost today is growing and the host populations who have been very welcoming over the past two years are no longer able to carry this burden. Despite the solidarity and the tremendous efforts of these countries to cope with the crisis, the various aid structures and schemes put in place are dysfunctional and will most likely remain so if the influx of refugees continues.

A late recognition of the magnitude and duration of the crisis and the ever growing numbers of refugees are the main reasons for the delays in the deployment of a response commensurate with the needs. But the level of assistance to the Syrian refugees must be urgently increased immediately in order to avoid a full-blown humanitarian crisis.

Since 2011 MSF has expanded its work with Syrian refugees in Lebanon, Jordan, Iraq and Turkey.

In Lebanon

Out of 300,000 Syrian refugees officially registered today in Lebanon according to the UNHCR, 220,000 have crossed the border since October. Large numbers of families are living in unfinished buildings, garages, warehouses and encampments which are utterly unsuitable to face the hardship of the winter. The main needs identified in studies conducted by MSF in December 2012 are accommodation, food, winterization items, primary and secondary health care, and mental health care. The Lebanese community has made a huge effort to assist the refugees. Though the situation in Lebanon remains relatively stable, the economic, social and political spillover of the war in Syria is having an impact on Lebanon as well, exacerbating sectarian tensions in impoverished neighborhoods of Tripoli. The Lebanese government has stated that it has no longer the means to face the burden of the refugees alone,1 and has asked the international community for more support.

1Lebanon suspends aid to Syrian refugees: PM office / AFP / 11.07.12

In Jordan

Over 240,000 Syrians refugees are registered or awaiting registration in Jordan. There are now 25 official reception points for refugees along the border, and many more unofficial crossing points. Some 40,000 Syrian refugees crossed the border in January alone. Za’atari camp, near the Syrian border, is now home to more than 60,000 refugees. The living conditions are totally inadequate. Hygiene conditions are poor due to a severe shortage of latrines and showers. This winter has been particularly harsh and Zaatari camp was partially flooded in January. Authorities have begun to relocate residents to prefabricated bungalows but most are still living in unheated tents that offer little protection from the elements.

In Iraq

The Kurdish Region Government (KRG) is hosting the Kurdish population that has fled Syria, while the central government in Baghdad has opened two camps in southwestern Iraq, the Al-Qa’im and Al Waleed camps. According to the UNHCR, as of mid-February 2013, there were 96,270 refugees in Iraq, including over 75,500 in the Kurdish Region.

Domeez camp was established in Duhok province in April 2012 and is managed by the UNHCR and the KRG authorities. Initially designed to host 1,000 families, the camp is now home to more than 50,000 people. Water and sanitation services are poor. The difficult living conditions for refugees are compounded by the winter weather and sub-zero temperatures.

Al Qaim border crossing, the only official border crossing for a distance of 400km [240 miles], remains closed. Although some of the sick or wounded are allowed to cross the border to seek medical assistance, MSF is concerned about the fate of people fleeing the ongoing fighting in Syria who are unable to find sanctuary in Iraq.

In Turkey

In Turkey, the refugee camps are managed by the Turkish authorities with the support of local actors such as the Turkish Red Crescent. According to the Turkish authorities, 183,540 Syrians have sought refuge in seven provinces and are hosted in 14 camps that are all nearly at capacity. Estimated figures of unregistered people range from 70,000 to 100,000 people. In Kilis, the estimated figures of both registered and unregistered Syrians inside and outside the camp are around 40,000. New camps are being opened but they cannot cope with the massive influx of refugees. Many people remain stuck at the Syrian border in so-called transit centers, waiting to be transferred to the camps. In addition, many of them try to cross on their own, settling in Kilis and surrounding areas.

Trapped by War, They Escaped and They Survive: Testimonies of Syrian Refugees in Lebanon and Iraq

1

“After a while they started bombing the towns and villages," says a father of eight. "The army sent tanks to demolish my house. They broke down the walls and entered with the tanks through the columns. Nothing was left of our house. We fled to another village, but there we were caught by heavy shelling, so I took the children who were terrified of the bombs and brought them to Aarsal in Lebanon."

“[In Syria] 400 bombs were falling per hour. We could not cope with the situation anymore, we have children. We had to sleep under trees, in a cave (grotto), in a valley to hide from the bombs. Finally we had no other choice than to flee to Lebanon to protect our children and our lives.”

2

“I arrived [to Iraq] from Syria four days ago," said a woman who arrived with her husband and five young children. "Our economic situation there was really bad. We came from Qamishli, where there is no gas, no electricity, no water, there is nothing. The city is completely besieged. We didn’t have any fuel for the heaters so we had to use tissues and whatever materials we could find. The children got ill because of the smoke, they suffered from respiratory irritation. This is why we came here. The trip was really difficult and very long."

The family is still waiting for a shelter.

5. MSF in and Around Syria

Prior to the Syrian uprising, MSF had a project in Damascus providing health care for migrants. This project was closed in April 2011. Then MSF repeatedly requested official access from the Syrian government in Damascus to be able to provide assistance based on needs, wherever those needs may be. But thus far, MSF has been denied the ability to work in Damascus and in areas controlled by the government.

Initially, MSF started supporting groups of Syrian doctors who were treating the wounded by supplying them with medicines and medical material. MSF re-entered the rebel held areas of the country unofficially in mid-2012 but were unable to enter government held areas. MSF now has three field hospitals in northern Syria and which the Syrian authorities have been informed of. Whilst initially MSF focused on providing emergency and surgical care, activities have extended to include primary health care consultations, maternal care, and organizing vaccination campaigns against polio and measles. MSF also provides donations of treatments for cutaneous leishmaniasis, communicable diseases such as typhoid and chronic illnesses such as asthma, diabetes and cardiovascular diseases.

In Syria, more than 1,500 surgical procedures and more than 20,800 outpatient and emergency consultations have been carried out by MSF teams between June 2012 and the end of February 2013. Many patients come for violence-related injuries such as gunshot wounds, shrapnel wounds, open fractures and injuries due to explosions. The admission of the wounded is irregular, depending on shifting frontlines and whether it is possible to refer patients.

Several other health facilities have been set up by Syrian doctors and other medical organizations to treat the wounded in the northern region. However, general access to health services remains limited for the population, particularly for people suffering from chronic illnesses. A significant number of MSF’s patients need treatment for chronic disease, accidental trauma, or assistance during childbirth.

MSF is also providing training in mass casualty management, triage, and emergency care to Syrian health personnel who need support in the management of war-wounded patients. Specific assistance is also being provided to medical facilities, such as setting up a blood bank in a health structure in Aleppo area.

MSF teams regularly carry out ad hoc distribution of relief items including baby milk and flour for affected families and donate medical material and medicine to other medical centers. Throughout 2012, MSF dispatched several tons of medical supplies and relief items to field hospitals and clinics in Syria, including into government-controlled areas.

Extending Assistance for Refugees in Neighboring Countries

MSF started supporting local initiatives to help refugees in Turkey in August 2011, and has since then increased its activities to include assistance to refugees in Lebanon, Iraq and Jordan. From the start of 2012 until January 2013, MSF has provided nearly 69,000 medical and mental health consultations to refugees in these four countries, mainly in Lebanon and Iraq.

In Lebanon, MSF is assisting Syrians through primary health care services, treatment of chronic diseases, antenatal care services, and mental health care, as well as distributing relief items. MSF is currently operating in Tripoli, in northern Lebanon, where the largest number of Syrian refugees is staying, as well as in the Bekaa valley, which is the main crossing point for people fleeing Syria.

In Iraq, MSF is the main health care provider in Domeez refugee camp where more than 50,000 people have settled. MSF is providing general health and mental health consultations, and immunization, and is also carrying out targeted distributions of hygiene kits as well as improving safe water supplies and efficient sanitation. MSF is also working in Al Qaim supporting the border clinic run by the Iraqi Ministry of Health and recently started providing mental health services in two refugee camps in the area.

In Jordan MSF provides reconstructive surgery to war-wounded refugees. Currently, Syrian surgical cases (mainly orthopedic) represent 40% of the new admissions in MSF's project in Amman, where they are offered physiotherapy, psychosocial support and post-operative care. MSF also runs outpatient consultations for Syrians from the Amman hospital.

In Turkey MSF is providing mental health support in partnership with Helsinki Citizens Assembly organization to the Syrian refugees living inside and outside camps, and has distributed relief items for refugee families living outside the camps who are not being helped by the existing aid system.

Overall Figures Up to February 28, 2013

Budget: The total for MSF operations in and around Syria in 2013 is €15.3 million, or approximately $19.88 million.

All our funding for programs in and around Syria comes from private donations.

Human Resources (Local and International Teams)

MSF has a total of 544 staff members working in and around Syria, including 229 in Syria, 58 in Turkey (including support and coordination staff), 118 in Lebanon, 75 in Iraq (not including teams working in other pre-existing programs in Iraq), and 64 in Jordan (not including the Amman hospital project).

Medical Activities Within Syria (Aleppo and Idlib governorates) Up to February 2013:

1,560 surgical acts were carried out by MSF in three hospitals in Syria, mostly for violence related injuries.

368 babies were delivered, mostly in the maternity ward in Aleppo, from November 2012 to January 2013.

Distributions in Syria

Over 166 tons of material were delivered including kits for treating wounded patients and for treating burns, surgical kits and donations of medical equipment such as oxygen extractors, transfusion kits, etc. In addition, 4,000 treatments for typhoid and 500 treatments for cutaneous leishmaniasis were provided in February 2013.

Relief items including wheat flour have been distributed inside the country and to 7,500 people living in transit camps next to the Turkish border in Aleppo governorate.